Meal Plan/Dining Accommodation Request Form
STUDENT NAME_____________________________________ DATE_____________
ADDRESS/BOX___________________________________ ID #_________________
PHONE ____________________ EMAIL ____________________________________
DURATION OF REQUEST: Short term/Long term ACADEMIC YEAR: ___________
NATURE OF INQUIRY/DIAGNOSIS:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
SPECIFIC ACCOMMODATION REQUEST:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
STUDENT SIGNATURE:
______________________________________________________________________
____ I will/have provide(d) medical documentation to Accommodative Services.
____ Permission given to discuss with the Special Accommodations Committee.
This form should be returned to: Shelly Shinebarger, Director
Accommodative Services, Union College
Reamer Campus Center Room 303
807 Union St., Schenectady, NY 12308
Email: shinebas@union.edu
ACTION TAKEN:
____ Referred to Union Dining Website
____ Interviewed student
____ More documentation requested
____Other _____________________________________________________________
Committee Decision ______________________________________________________
Letter Mailed____________________________________________________________
_______________________________________________________________________
Initials/Date
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